Authorization to Release Veterinary Records

You can submit this form in three different ways:

Download, print and fax us the “Authorization to Release Veterinary Records PDF Form” to (830) 393-6550
Download, print and email us the “PDF Form” to deasonah1990@yahoo.com
Fill out the digital form below:

Marked Fields are Required [*]

Please make a selection:(Required)

I would like to authorize Deason Animal Hospital to OBTAIN my pet’s records from another veterinarian

I would like Deason Animal Hospital to RELEASE my pet’s records to another hospital

Authorized Agent (Owner)(Required)

First Last

Patient Name(Required)

Current Veterinarian Info

Records are being requested to establish a full health history for an upcoming appointment with us at Deason Animal Hospital, 1712 D St. Floresville, TX 78114 Fax (830) 393-6550 or deasonah1990@yahoo.com For any questions, concerns, or issues; please call (830) 393-4567.

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Hospital's Email

Hospital's Fax #

Release my Pet's Records

Deason Animal Hospital will release your pet’s records to the following veterinary practice:

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Hospital Email

Hospital Fax

Additional Information

Please send the Patient’s(Required)

Vaccination Records

Full Medical History

X-Rays

Lab Work

I release the Veterinarian and staff members from any legal responsibility and liability or the release of information to the extent indicated as authorized herein. For any questions, concerns, or issues; please call (830) 393-4567.(Required)

I agree and accept

Client Identifying Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Client ID Number

Patient Identifying Information

Name(Required)

Gender(Required)

D.O.B.(Required)

Breed(Required)

Client Signature

Date

Phone

This field is for validation purposes and should be left unchanged.